COVID-19 in Long-Term Care Homes: Managing Symptoms and End-of-Life Care

The coronavirus disease 2019 (COVID-19) pandemic is causing significant challenges and suffering for residents and providers in long-term care homes (LTCHs). In Canada, LTCHs have become the epicenter of the pandemic, with residents accounting for more than 80% of the country’s COVID-19 deaths.¹ Worldwide, case fatality rates in the overall population vary between 1.5% and 6.5%, depending on the region.^2-4 

LTCH residents are especially vulnerable to COVID-19 because droplet-transmitted infections  spread easily in shared living spaces. In addition, many residents are of advanced age and have multiple comorbidities. Cardiovascular disease, diabetes mellitus, hypertension, chronic lung disease, chronic kidney disease, cancer, and dementia are all associated with severe COVID-19 illness and mortality.⁵ In Canadian LTCHs, 61% of residents have a diagnosis of dementia, and 40% of them exhibit behaviors related to dementia.⁶ Managing dementia complications such as dysphagia and behavior issues, such as wandering, pose unique challenges at a time when physical distancing and visitor restrictions are an integral component of society’s social prescription to control the pandemic.⁷ At a time of increased vulnerability in LTCHs, securing adequate staffing is also a challenge. Recent studies have shown an association between low staffing levels and COVID-19 infections within LTCHs.⁸ 

Consequently, LTCHs require a framework for symptom management of patients with COVID-19, including palliative and end-of-life (EOL) care. We propose a framework with considerations for respiratory symptom management and EOL care, specifically in LTCHs.

The following framework pertains to LTCH residents who test positive for COVID-19 and whose goals of care include supportive care. The most common symptoms associated with COVID-19 are presented in Box 1.⁹ Staff must be prepared to escalate medication dosing quickly to match the severity of symptoms, as COVID-19-related symptoms may advance quickly to a severe state. Administration of symptom control medications in LTCHs are dependent on staff familiarity and training around both the agents and modes of medication administration. With limited resources, access to medications and staff may become compromised. LTCHs should prepare ahead of time for access to essential medications
for comfort care and training, as applicable, for staff.

Goals of care, including individual wishes for cardiopulmonary resuscitation, should be revisited and updated in a COVID-19-positive resident regardless of symptom severity. The physician most responsible for care should discontinue all nonessential medications in residents experiencing respiratory distress. In the context of respiratory distress, consideration to discontinue subcutaneous or intravenous hydration is prudent, as residents receiving parenteral hydration may experience clinical fluid overload and worsening of symptoms such as dyspnea. Most symptom-control medications can be delivered parenterally through the subcutaneous route. 

Aerosol-generating medical procedures (AGMPs) should be avoided and include: (1) heated and humidified air/oxygen delivery systems; (2) oxygen flow greater than 6 L/min via nasal cannula; (3) high-flow nasal oxygen; and (4) continuous positive airway pressure (CPAP) or bilevel positive airway pressure. Nebulized treatments should be converted to metered-dose inhalers. Oral suctioning is considered non-AGMP, but deep suctioning requires AGMP precautions. For patients requiring CPAP for therapeutic indications, efforts should be made, if possible, for residents to put on their own masks to minimize staff exposure. Ideally, the lowest therapeutically beneficial positive pressures should be used. Infection prevention and control practices should be followed, in conjunction with local respiratory therapist input, with respect to the cleaning and storing of equipment.

The spectrum of symptomatic infection ranges from mild to critical.⁹ If residents can communicate, self-reporting of symptoms and their severity can be assessed using a validated and reliable tool. For noncommunicative residents, there are several scales for pain assessment.¹⁰ Treatment strategies should reflect symptom severity, prognosis, and goals of care within the context of balancing exposure risk to staff. 

Dyspnea 

Although residents may seem short of breath, it is important to ask whether they feel short of breath—this will guide management. Residents should be positioned as upright as they can tolerate. Supplemental oxygen can be provided to hypoxic patients and in some cases can help reduce the subjective work of breathing. Supplemental oxygen delivered by nasal prongs can be titrated to symptoms, not oxygen saturation. Avoid flow rates greater than 6 L/min to prevent aerosolization. 

Opioids are the standard for managing dyspnea. For residents not already taking opioids, consider starting low-dose opioids, such as morphine or hydromorphone, subcutaneously every 30 minutes as needed (PRN). If more than three administrations are required within 24 hours, reassess and titrate up the dose according to symptoms.Consideration should also be given for a standing dose of opioids, including continued access to PRN administrations. It is important to note that opioids do not hasten death in the context of dyspnea. If the resident is already taking oral opioids, consider increasing the dose by 25%. For residents in respiratory distress, nonoral routes of medication administration are preferable (eg, subcutaneous route). 

Adjuvants such as benzodiazepines can be used in conjunction with opioids to manage dyspnea and associated anxiety. Opioids and benzodiazepines can be used simultaneously in residents with severe respiratory distress. Benzodiazepines may need to be titrated to achieve sedation if distress is severe. 

Other Symptoms

Anticholinergics (eg, scopolamine) can be used to manage respiratory secretions; however, clinicians should be mindful that these may have a drying effect, which may thicken secretions and contribute to difficulty clearing. Diuretics can be administered via the subcutaneous route if the resident is volume overloaded. For agitation and restlessness, consider whether a nonsedating antipsychotic (eg, haloperidol) or a sedating antipsychotic (eg, methotrimeprazine) is required, both of which can be given parenterally. Nonsedating antipsychotics such as haloperidol can also manage nausea and vomiting. In cases where haloperidol is contraindicated, methotrimeprazine can be considered second choice for the management of agitation, distress, or nausea. Pain can be managed with opioids, similar to dyspnea. If a resident is on scheduled opioids for either management of dyspnea or pain, consideration should be given to using a scheduled laxative, including per rectum as needed. 

There are regional differences in what medications are considered essential and what medications are available for comfort care at the EOL during the COVID-19 pandemic. Table 1 presents an example of an order set used in LTCHs to manage dyspnea and EOL symptoms. We recommend, whenever possible, for each LTCH to connect with local palliative care consultants for specific, facility-level guidance. 

The uncertainty and fear related to COVID-19 in LTCHs is evident.¹¹ More so, no one knows how long the COVID-19 crisis will continue. 

The consequences of isolating older, frail residents cannot be understated. Residents in quarantine during the COVID-19 pandemic are at risk for a range of psychiatric symptoms and adverse psychological outcomes, such as anxiety, confusion, fear, depression, irritability, stress, and emotional exhaustion.¹² Many LTCHs have visitor restrictions, which can also contribute to overall distress, and increase risk for complicated grief and bereavement for families and caregivers alike. The need for a support system for families dealing with grief and bereavement is highlighted in the World Health Organization’s definition of palliative care.¹³ In the event of a patient’s death, some family members and caregivers may require additional interventions and support from social work, spiritual care, and other trained clinicians.^14,15 

In a similar way, many LTCH staff have long-term relationships with residents and have experienced heightened stress throughout the pandemic, including repeated exposure to residents experiencing severe COVID-19 symptoms, death, and dying. Care providers may grieve differently than families, but they grieve nonetheless. The risk of compassion fatigue, moral distress, and burnout has never been higher.¹⁶

Providing quality of life and quality of death is the core of the palliative approach to care in LTCHs. As the COVID-19 pandemic evolves, residents in LTCHs remain at great risk and have significant needs. Residents with COVID-19 require meticulous symptom assessment and compassionate management in the context of prognosis and goals of care. As morbidity and mortality during this pandemic are at levels previously unseen, the urgency for equitable access to palliative care has never been stronger. 

Authors: Giulia-Anna Perri, MD, CCFP, (COE), (PC)¹• Patrick Quail, MD, FCFP, CMD²• Nadia Incardona, MD, MHSc, CCFP, (EM)³• Leah Steinberg, MD, CCFP¹• Houman Khosravani, MD, PhD, FRCPC⁴ 

Affiliations:
¹Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
²Department of Family Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.
³Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
⁴Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada

Disclosures:
Authors report no relevant financial relationships. 

Address correspondence to:

Dr. Giulia-Anna Perri, MD, CCFP, (COE), (PC)
Baycrest Hospital
3560 Bathurst Street
Toronto, ON M6A 2E1

Phone: (416) 785-2500

Fax: (647) 800-6745

Email: gperri@baycrest.org